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Provider network participating request form - Oregon Alaska

Thank you for your interest in becoming a participating provider in the Moda Health network.

Contracting and credentialing are two separate processes that together provide In-Network status. Credentialing is the verification of specialties, education, and liability insurance. Contracting is the discussion of reimbursement rates and network participation. Being actively credentialed and contracted is the only way a practitioner can see Moda members as an In-Network provider.

To direct your request appropriately, please review the following scenarios and follow the instructions that apply to your request:

  1. Providers Joining an Already Contracted Clinic

    If you are joining a clinic that is already contracted with us, you do not need to review the following. Instead, please complete an Oregon credentialing application now. Once credentialing is completed, you will be given instructions on how to be added to the existing contract.

    Credentialing applications must be submitted it to the Credentialing department by email, fax or regular mail.

    Email: credentialing@modahealth.com
    Fax: 503-265-5707
    Mailing address:
    Moda Health
    Attn: Credentialing Dept.
    601 SW 2nd Ave. #900
    Portland, OR 97204

  2. Existing Providers:

    1. If you are a currently credentialed provider who is seeing Moda patients and you are leaving your existing clinic to contract under a new Tax ID, please complete the Existing Provider Contracting Request. Please note, contract requests will be reviewed and responded to within 20 business days. Providers that submit a request that do not fit the criteria as outlined above will not be responded to.
    2. If you are currently contracted through Idaho Physicians Network (IPN) and are seeking a direct contract with Moda Health due to the IPN termination, please complete the Existing Provider Contracting Request. Please note, direct contracts are only being offered to providers located in Ada, Adams, Canyon, Gem, Idaho, Owyhee, Payette and Washington counties. No requests will be accepted after 6/30/2022.
  3. New Providers:

    If you are a brand-new provider that is not currently credentialed with Moda Health and not joining an already contracted group, review the nominations panel below.

    Our Oregon, Washington, and Idaho panel is currently closed to new providers with the exception of Diversity, Equity, & Inclusion (DEI) providers. Our panel is reviewed bi-annually and will be updated in December 2022. If the panel is not open in your area at this time, please do not complete a credentialing application. We do not accept unsolicited credentialing applications for providers who have not been approved for participation via a Contract Request.

Check the panel now

Nominations Panel - Oregon
Category Specialties County Status

Diversity, Equity & Inclusion (DEI) Providers

NOTE: use the DEI Provider Contract request form

Providers who identify as or provide:

Black/African American Centered Care

Hispanic and Latinx Centered Care

Indigenous/Native American Centered Care

Asian and Pacific Islander Centered Care

LGBTQIA+ Centered Care

Sensory Disability Centered Care

Intellectual and Developmental Disability Centered Care

Veteran Centered Care

Bilingual Care

Culturally Specific Care

Gender Affirming Care

Open Counties:
All Counties

Primary Care

Family Practice
Geriatrics
Internal Medicine
Pediatrics

Closed Counties:
All Counties

Behavioral Health

ABA Therapy
Counselors
Licensed Clinical Social Worker
Licensed Marriage/Family Therapist
Psychiatry
Psychology
Mental Health Nurse Practitioner
Substance Use Disorder

Closed Counties:
All Counties

Alternative Care

Acupuncture
Chiropractic
Massage Therapy
Naturopath

Closed Counties:
All Counties

Therapies

Physical Therapy
Speech Therapy
Occupational Therapy

Closed Counties:
All Counties

All Other Specialties

All

Closed Counties:
All Counties

DME

All

Closed Counties:
All Counties

Lab

All

Closed Counties:
All Counties

Facilities

Dialysis Center
Home Health
Home Infusion
Hospice
Rehabilitation Center
Skilled Nursing Facility

Closed Counties:
All Counties

Nominations Panel - Washington
Category Specialties County Status

Diversity, Equity & Inclusion (DEI) Providers

NOTE: use the DEI Provider Contract request form

Providers who identify as or provide:

Black/African American Centered Care

Hispanic and Latinx Centered Care

Indigenous/Native American Centered Care

Asian and Pacific Islander Centered Care

LGBTQIA+ Centered Care

Sensory Disability Centered Care

Intellectual and Developmental Disability Centered Care

Veteran Centered Care

Bilingual Care

Culturally Specific Care

Gender Affirming Care

Open Counties:
Benton
Clark
Cowlitz
Walla Walla

Primary Care

Family Practice
Geriatrics
Internal Medicine
Pediatrics

Closed Counties:
All Counties

Behavioral Health

ABA Therapy
Counselors
Licensed Clinical Social Worker
Licensed Marriage/Family Therapist
Psychiatry
Psychology
Mental Health Nurse Practitioner
Substance Use Disorder

Closed Counties:
All Counties

Alternative Care

Acupuncture
Chiropractic
Massage Therapy
Naturopath

Closed Counties:
All Counties

Therapies

Physical Therapy
Speech Therapy
Occupational Therapy

Closed Counties:
All Counties

All Other Specialties

All

Closed Counties:
All Counties

DME

All

Closed Counties:
All Counties

Lab

All

Closed Counties:
All Counties

Facilities

Dialysis Center
Home Health
Home Infusion
Hospice
Rehabilitation Center
Skilled Nursing Facility

Closed Counties:
All Counties

Nominations Panel - Idaho
Category Specialties County Status

Diversity, Equity & Inclusion (DEI) Providers

NOTE: use the DEI Provider Contract request form

Providers who identify as or provide:

Black/African American Centered Care

Hispanic and Latinx Centered Care

Indigenous/Native American Centered Care

Asian and Pacific Islander Centered Care

LGBTQIA+ Centered Care

Sensory Disability Centered Care

Intellectual and Developmental Disability Centered Care

Veteran Centered Care

Bilingual Care

Culturally Specific Care

Gender Affirming Care

Open Counties:
Adams
Ada
Canyon
Gem
Owyhee
Payette

Primary Care

Family Practice
Geriatrics
Internal Medicine
Pediatrics

Closed Counties:
All Counties

Behavioral Health

ABA Therapy
Counselors
Licensed Clinical Social Worker
Licensed Family/Marriage Therapist
Psychiatry
Psychology
Mental Health Nurse Practitioner
Substance Use Disorder

Closed Counties:
All Counties

Alternative Care

Acupuncture
Chiropractic
Massage Therapy
Naturopath

Closed Counties:
All Counties

Therapies

Physical Therapy
Speech Therapy
Occupational Therapy

Closed Counties:
All Counties

All Other Specialties

All

Closed Counties:
All Counties

DME

All

Closed Counties:
All Counties

Lab

All

Closed Counties:
All Counties

Facilities

Dialysis Center
Home Health
Home Infusion
Hospice
Rehabilitation Center
Skilled Nursing Facility

Closed Counties:
All Counties

*The nominations panel was updated in February 2022 and is reviewed on a bi-annual basis

Check the panel now

Nominations Panel - Alaska
Category Specialties Burrough Status

Diversity, Equity & Inclusion (DEI) Providers

NOTE: use the DEI Provider Contract request form

Providers who identify as or provide:

Black/African American Centered Care

Hispanic and Latinx Centered Care

Indigenous/Native American Centered Care

Asian and Pacific Islander Centered Care

LGBTQIA+ Centered Care

Sensory Disability Centered Care

Intellectual and Developmental Disability Centered Care

Veteran Centered Care

Bilingual Care

Culturally Specific Care

Gender Affirming Care

Open Burroughs:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

Primary Care

Family Practice
Geriatrics
Internal Medicine
Pediatrics

Open Burroughs:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

Behavioral Health

ABA Therapy
Counselors
Licensed Clinical Social Worker
Licensed Family/Marriage Therapist
Psychiatry
Psychology
Mental Health Nurse Practitioner
Substance Use Disorder

Open Burroughs:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

Alternative Care

Acupuncture
Chiropractic
Massage Therapy
Naturopath

Open Burroughs:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

Therapies

Physical Therapy
Speech Therapy
Occupational Therapy

Open Burroughs:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

All Other Specialties

All

Submit for Review:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

DME

All

Submit for Review:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

Lab

All

Closed Burroughs:
All Burroughs

Facilities

Dialysis Center
Home Health
Home Infusion
Hospice
Rehabilitation Center
Skilled Nursing Facility

Submit for Review:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

*The nominations panel was updated in December 2021 and is reviewed on an annual basis.

Interested in joining our provider network? Please complete and submit the new provider network participation request form below. Note:

If you have not already reviewed our nominations panel, please do so before submitting the new provider network participation request form.

Check the panel now

Nominations Panel - Alaska
Category Specialties Burrough Status

Diversity, Equity & Inclusion (DEI) Providers

NOTE: use the DEI Provider Contract request form

Providers who identify as or provide:

Black/African American Centered Care

Hispanic and Latinx Centered Care

Indigenous/Native American Centered Care

Asian and Pacific Islander Centered Care

LGBTQIA+ Centered Care

Sensory Disability Centered Care

Intellectual and Developmental Disability Centered Care

Veteran Centered Care

Bilingual Care

Culturally Specific Care

Gender Affirming Care

Open Burroughs:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

Primary Care

Family Practice
Geriatrics
Internal Medicine
Pediatrics

Open Burroughs:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

Behavioral Health

ABA Therapy
Counselors
Licensed Clinical Social Worker
Licensed Family/Marriage Therapist
Psychiatry
Psychology
Mental Health Nurse Practitioner
Substance Use Disorder

Open Burroughs:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

Alternative Care

Acupuncture
Chiropractic
Massage Therapy
Naturopath

Open Burroughs:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

Therapies

Physical Therapy
Speech Therapy
Occupational Therapy

Open Burroughs:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

All Other Specialties

All

Submit for Review:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

DME

All

Submit for Review:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

Lab

All

Closed Burroughs:
All Burroughs

Facilities

Dialysis Center
Home Health
Home Infusion
Hospice
Rehabilitation Center
Skilled Nursing Facility

Submit for Review:
Anchorage
Fairbanks
Haines
Hannah-Angoon
Juneau
Kenai Peninsula
Ketchikan Gateway
Matanuska-Susitna
Petersburg
Prince of Wales
Sitka
Skagway
Wrangell

*The nominations panel was updated in December 2021 and is reviewed on an annual basis.

Contracting Request Form for Existing Providers

New provider network participation request form

*Specialty:

*Licensed to Practice In (check all that apply):







*County:
*Burrough:
*Provider name:
*Licensure:
*Current Clinic Name:
*Current Clinic Tax ID:
*Current Clinic Address:
*Date Leaving/Left Clinic (if applicable):
*New Clinic Name:
*New Clinic Tax ID:
*New Clinic Address:
*Starting Date with New Clinic:
*Business/Provider name:
*Tax ID:
*Type 1 NPI (Individual - if applicable):
*Type 2 NPI (Organizational - if applicable):
Medicare Eligible:



Medicare PTAN number:
Medicaid Eligible:



Medicaid DMAP number:
*New Clinic Primary Address:
Primary Address Line 2 (optional):
*New Clinic City:
*New Clinic State:
*New Clinic Zip Code:
*Provider first/last name:
*Primary Address:
Primary Address Line 2 (optional):
*City:
*State:
*Zip Code:
*Provider contact first/last name:
*Provider email:
*Office/Contracting first/last name:
*Office/Contracting email:
*Phone number:
Fax:
Notes, description of services:
*Required field  
Are you a behavioral health provider?



Are you currently seeing any Moda members?



Are contracted providers referring our members to you?



Are you requesting to be a Primary Care Provider (PCP)?



If, yes please provide the following information:

Are you a patient centered medical home?




Are you able to provide 24/7 coverage for members?



Are you able to provide pharmaceutical management to members with chronic conditions?




Complete the submission form in full, leaving no blank fields. We will review your information and contact you within 20 business days of your submission. Please note, this request form is for providers that are currently contracted and credentialed and leaving an existing clinic. Providers that submit a request that are not currently contracted and credentialed with Moda Health will not be responded to.

We will review your information and contact you within 60 days of your submission.

You can also submit a print version of this new provider network participation request form. to ProviderNominations@modahealth.com or by fax at ATTN: Provider Nominations 503-243-2964.

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Hello.

We have exciting news to share. ODS is changing its name to Moda Health.

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Together, we can be more, be better.

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